UNITED STATES DISTRICT COURT EASTERN DISTRICT OF MISSOURI DIVISION ) ) Petitioner, v. ) ) ) ) Respondent. ) MOTION TO PROCEED IN FORMA PAUPERIS AND AFFIDAVIT IN SUPPORTABEAS CASES I declare (1) that I am the petitioner in this case; (2) that because ofmypovertyIamunabletopaythefilingfeeand(3)thatI believeIamentitledtorelief.Thenatureofmyactionandthe issuesarebrieflystatedasfollows. In further support of this application, 1.Place of confinement of petitioner: 2.Crime(s) for which you have been convicted, date and sentence oneach: 3.Are you presently employed? Yes No a.If the answer is 'yes222 statetheamountofyoursalaryorwages per month and give the name and address of youremployer. ) American LegalNet, Inc. www.FormsWorkFlow.com b.Iftheansweris'no222statethedateoflastemploymentand the amount of the salary and wages per month which youreceived. 4.Have you received within the past twelve (12) months, moneyfrom any of the following sources? Yes No Business profession or form of self-employment Rent payments interest or dividend Pensions annuities or life insurance payments Gifts or inheritances Any other sources , If the answer to any of the above is 'yes222 describe the sourceand amount of money received from each during the past twelve(12) months. 5.Do you own any cash or do you have money in a checking orsavingsaccount?Includeanyfundsinyourprisonaccount. Yes No If the answer is 'yes222 statethetotalamountofcashowned, and the balance in all checking savings or prison accounts. 6.Doyouownrealestatestocksbondsnotesautomobiles,orother valuable property (excluding ordinary householdfurnishings and clothing) Yes No If the answer is 'yes222 approximate value. describe the property and state its 2 American LegalNet, Inc. www.FormsWorkFlow.com I 7. List the persons who are dependent upon you for support stateyourrelationshiptothosepersonsandindicatehowmuchyoucontributetowardtheirsupport I DECLARE UNDER PENALTY OF PERJURY THAT THE ABOVE INFORMATION IS TRUEANDCORRECT.IUNDERSTANDTHATPROVIDINGFALSEINFORMATION MAYSUBJECTMETOCRIMINALPROSECUTIONIMPOSITIONOFAFINEOR OTHERSANCTIONTHATMAYADVERSELYAFFECTMYABILITYTOPURSUETHIS CASEOROTHERCASES.IHAVEREVIEWEDMYANSWERSTOINSURETHEIR ACCURACY Executed (signed) this day of 20. (Signature of petitioner) Certificate I certify that the applicant named herein has the sum of $ on account to his credit at the she confined. I further certify that theapplicantlikewisehasthe followingsecuritiestohiscreditaccordingtotherecordsofsaid institution Authorized Officer of Institution 3 American LegalNet, Inc. www.FormsWorkFlow.com